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Conflict Between Doctor and Patient

Conflict between doctor and patient is inevitable. Their training, perspective, and stake in any clinical decision are markedly different. Yet clinical interaction and the scholarship are rife with efforts to avoid that conflict. Jay Katz has famously explored physician silence as a strategy of avoidance; he argues that the systematic avoidance of conflict is a tradition in medicine, grounded in ancient paternalistic commitments. Yet even the reconceptualized doctor-patient relationship born of modern bioethics sweeps conflict under the rug. Numerous articles on decisions to forgo resuscitation, for instance, speak euphemistically of patient "participation" in the decision, failing to face the fact that the patient’s refusal of life-sustaining treatment controls. In the clinic too, the prevailing notion is that if the clinician is skilled enough, the patient can be managed and conflict prevented.

This article is an attempt to take conflict in the relationship seriously. It is an examination of the persistence of old strategies to avoid conflict, including continued silence, and the emergence of new ones, such as physician claims that they need not discuss with patients treatments the physician deems futile. Physicians also are asserting claims of conscientious refusal, allowing a doctor who disagrees with a patient’s choice to withdraw from the case. The article analyzes these responses to doctor/patient conflict and finds them deeply problematic.

To ignore the inevitability of doctor/patient conflict – to prioritize harmony, "shared decision-making," and "patient participation" – is to revive in new form the old practice of ignoring the differences between the interests and perspectives of doctor and patient. To take those differences seriously, means accepting disagreement and working with it. It means trading the peacefulness of silence for the rough-and-tumble of real conversation.